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A 7025651 2Q14A I � � 1. The Insur�: 3urfcomber fnc � D8�4: MaiNltg ad�'968: 107 Soud1 St10r8 DfWe �EIN:"`-"" i South Yam�outh,MA a2864 I Le�al Entity Type: Corporatlon � Qther wo�iCplaoes not shown above: See Location i 2. The p01iCy period is from 07/0112095 to 07/072078 12:018.m.atandmd time et the h�sured's�i�ng address. � 3. A Waker�s Compenssfbn Insurance:PaR One af ihe poticy s�Nes to tfre Workers Compsnaation L.aw of tha � sta�es nece�nero: n�a B. Ernpfoyers'LtabB'�ty k�urar►ce:Part 7Uw of tha Po�cY�piieS to wOrk�n each state�sCad in item 3.A. I The fimita of�ebiliry�mder Part Two are: 8odih►�njurY b}+Aoc�deM $ 500.000 each axident � Hodiy Injury by Dis�se S 500.p00�Ncy ilmit i ��Y��{Y aY�ase S SQQ,OOD each employee C. Od�er States Insw�anoe: Covera4e Reptaoed by Endorsemeni WC 20 03 06 B D. This fbl�.y indudes these Endorsemsnts and Schedules: SEE SCNEDULE 4. The prerNum tor tfNs policy wlll be detetmir�ed by our Ma�uafs of Rutes.qassiflcations,Rates arW Ftatirig Plans. ' Ad icrtannauon teq�red beiow is sut�ct to vertNc�tion and d�nge by aud+l. Clas 's�ficedions '�� Premium Basis Rates ! Cod� F�tim�ed Per 5100 E�ed � No. Tot�Mrwsl Of Mouai Rerttunetation Reawr�rotion Premiwn ' . � IM'RA 1202Q4 ' IM'ER CLAS3 CODE SCH Mirum�n Premiurn a284 Tota!Estimated Arxwat Premium $4,057 GOV GOV ����m �� . STATE C1A5S ' MA 9032 State AssessmentslSurc�harge6 $3,800.�x 5.80009y 5209 This poGcy,includ�g al!e�xlor�aments�is ttereby c:onn�aigned by ``�^� -�~`"�''`- L��- 06N3/ZQ15 • � re p� Senrice Oifioe: HUB Irrtema�onal Ndw 6tgland LLC , Burtington MA 01803 299 Ba�ardve�e Stteet i W�mingMn,MA 0'1887 VInC 00 00 01 A(7-11) u�cwdRs eap�rA�Maa�erw a aw I�oa�d couna�oa G1omp�nsuton Inwr.nc., us�d Mq�ils p1�nnMtlon. i � � � The Commonwealth ofMassachuseits ; Department of Industrial Accidents i 1 Congress Stree�Suite 100 Boston,MA 02II4-20I7 www mass.gov/dia Workers'Compensadon Insur�nce Af�davit:Geaeral Bnsinesses. TO BE FILED WITH TRE PETLIVRTTING ATJT'HORiTY. ; Apt�licant Information Please Print Le�iblv � ; � Business/Organization Name: $v�C.o�n�g�It tr.�� � � �s I Address: l a� 7a;� S�w C�- p�-t�/'� City/State/Zip: S. uH��M�,rY� l VU} !�266�Phone#: Fj' �►L��-�`�8-Q 2'L$ Are you an employer?Ch�k tLe appropriate bax; Business Type(required): , 1.�' I am a ennployer with�_employees(full and/ 5. ❑Retail or part-time).* 6. �Restaurant/Baz1FaYing Establishment 2.❑ I am a sole proprietor or partnership and have no �, �pffice and/or Sales(incl.real estate,auto,etc.) emp loyees wor l ang for me in any capacity. (No workers'comp.insurance required] g• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑E.ntertainment tlaeir right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers'comp.insurance required)* 4.❑ We are a non-profit organization,staffed by volutnteers, 11.Q Health Car$ with no employees.jNo workers'comp.insurance req.] 12.�Other a �� ,� `�Y aPPlicant that checks boz#1 must atso fili oat 1i�e section below showing theQ woiiceis'compensation policy infarmatioa. •'If thc co[porate officeas have ezempted themselves,but tlte COTporation has other employees,a woikcis'compeasation policy is rtquifed aud sncL au organization shouid chcck bo�c#1. I arn are employer tliat is prov�ding wor�rers'compensatioa ansurance for my employees. Below is the policy information. Insurance Company Name: _�.l_M M u��A, 1 r+S�t wnL� Ce a►,va�► Insurer's Address: St'I �b►�r! Av�„T City/State/Zip:__(3 uf�r�j� .---�A --,�.'�'�A3 Policy#or Self-ins.Lic,# AW L ' ��d"�D Z, 65L 1 - 2a���_Expiration Date: U� 0� l Attac6 a copy of the workers'compensation policy dectaration page(showing the policy number and zpiratiou date). Failure to s�ure covcrage as required under Section 25A of MGL c. 152 caa lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yeaz imprisonment,as well as civii penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement xnay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ' I do here6y certif'y the pain peRalties of thot tlse ircfarmation provfded above is true a�ed correet i Si ature: Date: � O( t O OfJie�lal use onYy. Do not write in this arery to be cam�pleted by city or town of�cial City or Town: Permit/License# Issuing Anthority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person• � Phone#• www.mass.gov/dia